C O M M E N TA RY
pii: jc-00468-14 http://dx.doi.org/10.5664/jcsm.4352
Treating Nightmares—Sleep Medicine and Posttraumatic Stress Disorder Commentary on Seda et al. Comparative meta-analysis of prazosin and imagery rehearsal therapy for nightmare frequency, sleep quality, and posttraumatic stress. J Clin Sleep Med 2015;11:11–22. James F. Pagel, MS, MD University of Colorado School of Medicine, Pueblo, CO
P
osttraumatic stress disorder (PTSD) is arguably the most physiologically dangerous of the diagnoses addressed by the field of Sleep Medicine. Of major psychiatric and medical diagnoses, PTSD is associated with the highest risk for both successful and unsuccessful suicide attempts.1 For some at risk populations (e.g., psychiatrically hospitalized adolescent offspring of war-associated PTSD veterans), the prevalence of suicide attempts exceeds sixty percent.2 This risk of suicidal behavior exists independent of comorbid depression3,4 and is present even when the symptoms of PTSD are subthreshold in meeting criteria for the full diagnosis.5 The personal and social tolls for PTSD extend beyond suicide. Individuals with PTSD are far more likely to engage in substance abuse and risk taking behaviors including aggressive driving.6,7 The social sequelae of PTSD include job loss, divorce, homelessness, as well as increased risks for child and domestic abuse, sexual assault, violent crime, and re-incarceration.8 PTSD is treated with a wide variety of medication and psychological therapies. The most commonly utilized approaches, based on governmental and military recommendations for therapy, include various approaches to exposure therapy coupled with antidepressant and antianxiety medication.9–11 Exposure therapy, as utilized in Critical Incidence Stress Debriefing (CISD), is the most commonly utilized behavioral therapy for PTSD.11,12 Since, when applied acutely, CISD can lead to increased symptoms for some patients, the American Psychiatric Association has called into question its routine use.13 While this approach to therapy for PTSD has been shown to diminish PTSD symptomatology, none of the current therapies for PTSD have been shown to reduce the occurrence of PTSD when utilized acutely after trauma, or to reduce the chance that PTSD will become a lifelong disorder.14,15 For many severely traumatized individuals, symptoms of PTSD persist into extreme old age.16 Nightmares are the most commonly reported symptom of PTSD.17 Among therapists utilizing exposure therapy to treat PTSD, some have the perspective that nightmares of the traumatic experience may be therapeutic—a useful part of the re-experience approach to therapy. Based on this perspective, some overviews of PTSD diagnosis and therapy deemphasize the role of recurrent nightmares both as a symptom and as a component of the diagnosis.18
The field of Sleep Medicine has suggested an alternative approach to treating PTSD: proposing that the recurrent nightmares of PTSD lead to insomnia and next-day waking distress that contributes to waking symptoms of PTSD.19 This approach fits with an overall perspective that treating insomnia in psychiatric disorders can have significant benefits. This apparently logical perspective, however, lacks the support of long-term prospective epidemiologic studies.20 The Seda et al. paper in this issue,21 a comparative metaanalysis of medications and behavioral treatments available for treating nightmares, indicates that both of these approaches can be used to produce excellent results in reducing nightmare frequency, insomnia and next day distress. This meta-analysis is an excellent and needed next step for supporting a role for Sleep Medicine based nightmare therapies in the treatment of PTSD. While nightmare frequency is quite easy to measure, the objective of these therapies when used to treat patients with PTSD is not to just decrease nightmares and insomnia, but rather to decrease waking PTSD symptoms, morbidity, and mortality. These variables are far more difficult to measure. The first of these studies, reviewed favorably in Seda et al., indicate positive short-term effects for suppressing nightmares in patients with PTSD. Much more work is required if nightmare suppression is to become an accepted and main-line approach to treating this common, difficult, and dangerous diagnosis. Epidemiological studies are required that include long-term prospective followup and comparison to exposure-, antidepressant-, and antianxiety-treated PTSD populations. The field of Sleep Medicine has developed behavioral and pharmacological approaches that can be clearly demonstrated to suppress nightmares. Relative to PTSD, we find ourselves in a similar position to that in the early days of OSA in which we had a treatment for a disorder (PAP) yet little evidence clinically justifying and supporting its use. Just as with OSA, there are huge numbers of individuals suffering from a physiologically dangerous diagnosis that has high personal and social cost as well as demonstrated adverse effects on morbidity and mortality. Currently utilized medication and psychological approaches have limited efficacy, so that for many of those affected, PTSD becomes a chronic, disabling, and lifelong disorder. It is important not just for the affected patients, but for the researchers, therapists, and clinicians in the field to invest 9
Journal of Clinical Sleep Medicine, Vol. 11, No. 1, 2015
Pagel JF
the considerable effort required to prove the short and longterm efficacy of nightmare suppression when utilized to treat patients with PTSD.
12. Jacobs J. Horne-Moyer H, Jones R. The effectiveness of critical incidence stress debriefing with primary and secondary trauma victims. Int J Emerg Ment Health 2004;6:5–14. 13. American Psychiatric Association. Practice guidelines treatment of patients with acute stress disorder and posttraumatic stress disorder. http://psychiatryonline. org/guidelines.aspx. Accessed Oct 8, 2014. 14. Santiago P, Uiasao R, Gray C, et al. A systematic review of PTSD prevalence and trajectories in DSM-5 defined trauma-exposed populations: intentional and non-intentional traumatic events. PLOS One 2013;8:e59236. 15. Roberts NP, Kitchiner NJ, Kenardy J, Bisson JI. Multiple session early psychological interventions for the prevention of post-traumatic stress disorder. Cochrane Database Syst Rev 2009;3:CD006869. 16. Sadavoy J. Survivors. A review of the late-life effects of prior psychological trauma. Am J Geriatr Psychiatry 1997;5:287–301. 17. Ross R, Ball W, Sullivan K, Caroff S. Dream disturbance as the hallmark of posttraumatic stress disorder. Am J Psychiatry 1989;146:697–707. 18. Holloway R, Butler D. Treatment of posttraumatic stress disorder can be complex. Am Fam Physician 2004;70:1031–7. 19. Aurora RN, Zak RS, Auerbach SH, et al. Best practice guide for the treatment of nightmare disorder in adults. J Clin Sleep Med 2010;6:389–401. 20. Pagel JF, Pegram V. Sleep medicine: evidence based clinical practice. In: Pagel JF, Pandi-Perumal, SR, eds. Primary care sleep medicine: a practical guide. 2nd ed. New York: Springer Press, 2014. 21. Seda G, Sanchez-Ortuno MM, Welsh CH, Halbower AC, Edinger JD. Comparative meta-analysis of prazosin and imagery rehearsal therapy for nightmare frequency, sleep quality, and posttraumatic stress. J Clin Sleep Med 2015;11:11–22.
CITATION Pagel JF. Treating nightmares—sleep medicine and posttraumatic stress disorder. J Clin Sleep Med 2015;11(1):9–10.
REFERENCES 1. Calabrese JR, Prescott M, Tamburrino M, et al. PTSD comorbidity and suicidal ideation associated with PTSD within the Ohio Army National Guard. J Clin Psychiatry 2014;72:1072–8. 2. Boricevic Marsanic V, Margetic BA, Zecevic I, Herceg M. The prevalence and psychosocial correlates of suicide attempts among inpatient adolescent offspring of Croatian PTSD male war veterans. Child Psychiatry Hum Dev 2014;45:577–87 3. Cougle JR, Resnick H, Kilpatrick DG, PTSD, depression and their comorbidity in relation to suicidality: cross sectional and prospective analysis of a national probability sample of women. Depress Anxiety 2009;28:1151–7. 4. Ramsawh HJ, Fullerton CS, Mash HB, et al. Risk for suicidal behaviors associated with PTSD, depression, and their comorbidity in the U. S. Army. J Affect Discord 2014;161:116–22. 5. Marshall RD, Olfson M, Hellman F, et al. Comorbidity, impairment, and suicidality in subthreshold PTSD. Am J Psychiatry 2000;158:1467–73. 6. Mills KL, Teesson M, Ross J, Peters L. Trauma, PTSD, and substance abuse disorders: findings from the Australian National Survey of Mental Health and Well-Being. Am J Psychiatry 2006;163:652–8. 7. Strom TQ, Leskela J, James LM, et al. An exploratory examination of risk taking behavior and PTSD severity in a veteran sample. Mil Med 2014;177:390–6. 8. Ardino V, Milani L, Di Blasio P. PTSD and re-offending risk: the mediating role of worry and a negative perception of other people’s support. Eur J Psychotraumatol 2013 Dec 20;4. 9. Department of Veteran Affairs, Department of Defense. VA/DoD clinical practice guideline for management of post-traumatic stress. http://www.healthquality. va.gov/guidelines/MH/ptsd/cpg_PTSD-FULL-201011612.pdf. Accessed Jan 1, 2014. 10. Stein D, Ipser J, Seedal S. Pharmacotherapy for post traumatic stress disorder (PTSD). Cochrane Database Syst Rev 2006;1:CD002795. 11. Bisson J, Roberts N, Andrew M, et al. Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults. Cochrane Database Syst Rev 2013;12:CD003388.
Journal of Clinical Sleep Medicine, Vol. 11, No. 1, 2015
SUBMISSION & CORRESPONDENCE INFORMATION Submitted for publication November, 2014 Accepted for publication November, 2014 Address correspondence to: James F Pagel, MD, FAASM, Rocky Mountain Sleep, 1306 Fortino Blvd, Pueblo, CO 81008; Tel: (719) 584-4297; Fax: (719) 586-9794; E-mail: [email protected]
DISCLOSURE STATEMENT Dr. Pagel has indicated no financial conflicts of interest.
10
pii: jc-00468-14 http://dx.doi.org/10.5664/jcsm.4352
Treating Nightmares—Sleep Medicine and Posttraumatic Stress Disorder Commentary on Seda et al. Comparative meta-analysis of prazosin and imagery rehearsal therapy for nightmare frequency, sleep quality, and posttraumatic stress. J Clin Sleep Med 2015;11:11–22. James F. Pagel, MS, MD University of Colorado School of Medicine, Pueblo, CO
P
osttraumatic stress disorder (PTSD) is arguably the most physiologically dangerous of the diagnoses addressed by the field of Sleep Medicine. Of major psychiatric and medical diagnoses, PTSD is associated with the highest risk for both successful and unsuccessful suicide attempts.1 For some at risk populations (e.g., psychiatrically hospitalized adolescent offspring of war-associated PTSD veterans), the prevalence of suicide attempts exceeds sixty percent.2 This risk of suicidal behavior exists independent of comorbid depression3,4 and is present even when the symptoms of PTSD are subthreshold in meeting criteria for the full diagnosis.5 The personal and social tolls for PTSD extend beyond suicide. Individuals with PTSD are far more likely to engage in substance abuse and risk taking behaviors including aggressive driving.6,7 The social sequelae of PTSD include job loss, divorce, homelessness, as well as increased risks for child and domestic abuse, sexual assault, violent crime, and re-incarceration.8 PTSD is treated with a wide variety of medication and psychological therapies. The most commonly utilized approaches, based on governmental and military recommendations for therapy, include various approaches to exposure therapy coupled with antidepressant and antianxiety medication.9–11 Exposure therapy, as utilized in Critical Incidence Stress Debriefing (CISD), is the most commonly utilized behavioral therapy for PTSD.11,12 Since, when applied acutely, CISD can lead to increased symptoms for some patients, the American Psychiatric Association has called into question its routine use.13 While this approach to therapy for PTSD has been shown to diminish PTSD symptomatology, none of the current therapies for PTSD have been shown to reduce the occurrence of PTSD when utilized acutely after trauma, or to reduce the chance that PTSD will become a lifelong disorder.14,15 For many severely traumatized individuals, symptoms of PTSD persist into extreme old age.16 Nightmares are the most commonly reported symptom of PTSD.17 Among therapists utilizing exposure therapy to treat PTSD, some have the perspective that nightmares of the traumatic experience may be therapeutic—a useful part of the re-experience approach to therapy. Based on this perspective, some overviews of PTSD diagnosis and therapy deemphasize the role of recurrent nightmares both as a symptom and as a component of the diagnosis.18
The field of Sleep Medicine has suggested an alternative approach to treating PTSD: proposing that the recurrent nightmares of PTSD lead to insomnia and next-day waking distress that contributes to waking symptoms of PTSD.19 This approach fits with an overall perspective that treating insomnia in psychiatric disorders can have significant benefits. This apparently logical perspective, however, lacks the support of long-term prospective epidemiologic studies.20 The Seda et al. paper in this issue,21 a comparative metaanalysis of medications and behavioral treatments available for treating nightmares, indicates that both of these approaches can be used to produce excellent results in reducing nightmare frequency, insomnia and next day distress. This meta-analysis is an excellent and needed next step for supporting a role for Sleep Medicine based nightmare therapies in the treatment of PTSD. While nightmare frequency is quite easy to measure, the objective of these therapies when used to treat patients with PTSD is not to just decrease nightmares and insomnia, but rather to decrease waking PTSD symptoms, morbidity, and mortality. These variables are far more difficult to measure. The first of these studies, reviewed favorably in Seda et al., indicate positive short-term effects for suppressing nightmares in patients with PTSD. Much more work is required if nightmare suppression is to become an accepted and main-line approach to treating this common, difficult, and dangerous diagnosis. Epidemiological studies are required that include long-term prospective followup and comparison to exposure-, antidepressant-, and antianxiety-treated PTSD populations. The field of Sleep Medicine has developed behavioral and pharmacological approaches that can be clearly demonstrated to suppress nightmares. Relative to PTSD, we find ourselves in a similar position to that in the early days of OSA in which we had a treatment for a disorder (PAP) yet little evidence clinically justifying and supporting its use. Just as with OSA, there are huge numbers of individuals suffering from a physiologically dangerous diagnosis that has high personal and social cost as well as demonstrated adverse effects on morbidity and mortality. Currently utilized medication and psychological approaches have limited efficacy, so that for many of those affected, PTSD becomes a chronic, disabling, and lifelong disorder. It is important not just for the affected patients, but for the researchers, therapists, and clinicians in the field to invest 9
Journal of Clinical Sleep Medicine, Vol. 11, No. 1, 2015
Pagel JF
the considerable effort required to prove the short and longterm efficacy of nightmare suppression when utilized to treat patients with PTSD.
12. Jacobs J. Horne-Moyer H, Jones R. The effectiveness of critical incidence stress debriefing with primary and secondary trauma victims. Int J Emerg Ment Health 2004;6:5–14. 13. American Psychiatric Association. Practice guidelines treatment of patients with acute stress disorder and posttraumatic stress disorder. http://psychiatryonline. org/guidelines.aspx. Accessed Oct 8, 2014. 14. Santiago P, Uiasao R, Gray C, et al. A systematic review of PTSD prevalence and trajectories in DSM-5 defined trauma-exposed populations: intentional and non-intentional traumatic events. PLOS One 2013;8:e59236. 15. Roberts NP, Kitchiner NJ, Kenardy J, Bisson JI. Multiple session early psychological interventions for the prevention of post-traumatic stress disorder. Cochrane Database Syst Rev 2009;3:CD006869. 16. Sadavoy J. Survivors. A review of the late-life effects of prior psychological trauma. Am J Geriatr Psychiatry 1997;5:287–301. 17. Ross R, Ball W, Sullivan K, Caroff S. Dream disturbance as the hallmark of posttraumatic stress disorder. Am J Psychiatry 1989;146:697–707. 18. Holloway R, Butler D. Treatment of posttraumatic stress disorder can be complex. Am Fam Physician 2004;70:1031–7. 19. Aurora RN, Zak RS, Auerbach SH, et al. Best practice guide for the treatment of nightmare disorder in adults. J Clin Sleep Med 2010;6:389–401. 20. Pagel JF, Pegram V. Sleep medicine: evidence based clinical practice. In: Pagel JF, Pandi-Perumal, SR, eds. Primary care sleep medicine: a practical guide. 2nd ed. New York: Springer Press, 2014. 21. Seda G, Sanchez-Ortuno MM, Welsh CH, Halbower AC, Edinger JD. Comparative meta-analysis of prazosin and imagery rehearsal therapy for nightmare frequency, sleep quality, and posttraumatic stress. J Clin Sleep Med 2015;11:11–22.
CITATION Pagel JF. Treating nightmares—sleep medicine and posttraumatic stress disorder. J Clin Sleep Med 2015;11(1):9–10.
REFERENCES 1. Calabrese JR, Prescott M, Tamburrino M, et al. PTSD comorbidity and suicidal ideation associated with PTSD within the Ohio Army National Guard. J Clin Psychiatry 2014;72:1072–8. 2. Boricevic Marsanic V, Margetic BA, Zecevic I, Herceg M. The prevalence and psychosocial correlates of suicide attempts among inpatient adolescent offspring of Croatian PTSD male war veterans. Child Psychiatry Hum Dev 2014;45:577–87 3. Cougle JR, Resnick H, Kilpatrick DG, PTSD, depression and their comorbidity in relation to suicidality: cross sectional and prospective analysis of a national probability sample of women. Depress Anxiety 2009;28:1151–7. 4. Ramsawh HJ, Fullerton CS, Mash HB, et al. Risk for suicidal behaviors associated with PTSD, depression, and their comorbidity in the U. S. Army. J Affect Discord 2014;161:116–22. 5. Marshall RD, Olfson M, Hellman F, et al. Comorbidity, impairment, and suicidality in subthreshold PTSD. Am J Psychiatry 2000;158:1467–73. 6. Mills KL, Teesson M, Ross J, Peters L. Trauma, PTSD, and substance abuse disorders: findings from the Australian National Survey of Mental Health and Well-Being. Am J Psychiatry 2006;163:652–8. 7. Strom TQ, Leskela J, James LM, et al. An exploratory examination of risk taking behavior and PTSD severity in a veteran sample. Mil Med 2014;177:390–6. 8. Ardino V, Milani L, Di Blasio P. PTSD and re-offending risk: the mediating role of worry and a negative perception of other people’s support. Eur J Psychotraumatol 2013 Dec 20;4. 9. Department of Veteran Affairs, Department of Defense. VA/DoD clinical practice guideline for management of post-traumatic stress. http://www.healthquality. va.gov/guidelines/MH/ptsd/cpg_PTSD-FULL-201011612.pdf. Accessed Jan 1, 2014. 10. Stein D, Ipser J, Seedal S. Pharmacotherapy for post traumatic stress disorder (PTSD). Cochrane Database Syst Rev 2006;1:CD002795. 11. Bisson J, Roberts N, Andrew M, et al. Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults. Cochrane Database Syst Rev 2013;12:CD003388.
Journal of Clinical Sleep Medicine, Vol. 11, No. 1, 2015
SUBMISSION & CORRESPONDENCE INFORMATION Submitted for publication November, 2014 Accepted for publication November, 2014 Address correspondence to: James F Pagel, MD, FAASM, Rocky Mountain Sleep, 1306 Fortino Blvd, Pueblo, CO 81008; Tel: (719) 584-4297; Fax: (719) 586-9794; E-mail: [email protected]
DISCLOSURE STATEMENT Dr. Pagel has indicated no financial conflicts of interest.
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